On August 3, 1982, a 56-year-old woman residing in Los Angeles
County, California, developed diplopia, weakness, difficulty
breathing, and chest pain. She had respiratory arrest on admission
to
the hospital but was intubated, resuscitated, and placed in
intensive
care. Examination showed complete bilateral ptosis,
ophthalmoplegia,
facial muscle weakness, and areflexia. Cerebrospinal fluid was
normal
except for increased glucose; Tensilon test was negative. She had
a
past history of seizure disorder, diabetes mellitus, and organic
brain
syndrome. An infectious disease consultant thought her subsequent
fever was due to pneumonia secondary to aspiation, and he suspected
botulism as the underlying cause of her illness.

The patient lives with her husband and grown son who both
prepare
meals for her and attempt a strict diet in consideration of her
diabetes. When asked about the patient's food history before onset
of
illness, the husband and son named no likely suspects for botulism.
No
home-preserved foods had been served, and, with one exception, she
had
not eaten other foods that were not freshly prepared for her or
were
not also consumed by her husband and son. The exception was
commercial beef pot pie, which was accidently mishandled, then
consumed by the patient 1 day before illness began.

The son had prepared the pot pie for an earlier evening meal.
The
frozen pie was baked in an oven for 40-45 minutes. As he was about
to
serve it to his mother, his father came home with some freshly
cooked
hamburgers just purchased at a take-out restaurant. The pot pie
was
put aside on an unrefrigerated shelf. Two and one-half days later,
the son came home and found his mother had just consumed this pot
pie
without reheating it.

An uneaten portion of the pot pie, still in its metal plate,
was
retrieved by the family members. Type A botulism toxin was found
in
this pie by a mouse-inoculation test performed at a U.S. Department
of
Agriculture laboratory in Beltsville, Maryland, and type A toxin
was
also demonstrated in the patient's serum by the state's Microbial
Disease Laboratory.

Editorial Note

Editorial Note: This is the third case of botulism associated with
commercial pot pies reported from California (1,2); one other
episode
(involving two clinically diagnosed patients) was reported from
Minnesota in 1960 (3). Mishandling of the pot pies occurred in
three
of these episodes, and mishandling was also suspected in the
fourth.
The known mishandlings consisted of leaving the baked pot pie in
the
oven with the pilot light on, thereby maintaining "incubator"
temperatures overnight. The pies were then eaten with no (or
insufficient) reheating to destroy toxin. Or, as in the present
case,
the baked pie sat out at room temperature for over 2 days during
hot
weather--conditions that also could simulate an incubator.

In these situations, it is suspected that the original baking
killed competing organisms in the pies and eliminated much of the
oxygen. The heat-resistant, anaerobic Clostridium botulinum, which
was evidently present and can be found in many fresh, frozen, and
other food products, was then presumably able to germinate and
produce
toxin under the crust during storage at warm, incubator-like
temperatures. Products such as pot pies should be kept frozen
before
heating and ideally should be served hot after the first cooking.
If
any such products are to be saved, it should be quickly
refrigerated,
then reheated to hot temperatures. This would minimize any risk of
botulinal poisoning.
Reported in California Morbidity, November 12, 1982;(44).

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